Healthcare Provider Details

I. General information

NPI: 1912202805
Provider Name (Legal Business Name): GENRIKH GANDELSMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 FALLING WATERS BLVD
LINDENHURST IL
60046-6793
US

IV. Provider business mailing address

3065 FALLING WATERS BLVD
LINDENHURST IL
60046-6793
US

V. Phone/Fax

Practice location:
  • Phone: 224-643-4381
  • Fax:
Mailing address:
  • Phone: 224-643-4381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001887
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: